United States: The updated clinical practice guidelines on restless legs syndrome (RLS) by the American Academy of Sleep Medicine (AASM) last fall recommended against the routine application of dopamine agonists, citing augmentation.
Augmentation, which is the slow growth in symptoms, has been identified as experienced by people with RLS 30 years ago by sleep experts.
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Over the last ten years, there was increasing opinion that dopaminergic drugs caused augmentation of RLS (affecting 7 to 10 percent of individuals annually).
In a statement through the AASM, John Winkelman, MD, PhD, chief of the sleep disorders clinical research program at Massachusetts General Hospital and chair of the AASM committee that revised the guideline, explained that 7 to 10 percent does not sound like much, but multiply it by 3 years, it is 20 to 30 percent of patients with RLS, hcplive.com reported.
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Within 5 years, a percentage of 35-50 of the people will grow. Leaving the world of dopamine agonists behind, the guidelines have added a few iron preparations to the list as well: the intravenous iron and the oral iron, and three alpha two delta calcium channel ligands, which are gabapentin, gabapentin enacarbil, and pregabalin.
Winkelman (2024) released an article in December 2024 on the HCPLive site informing them about these new guidelines and providing the HomeRls Curbside resource, which is a peer-to-peer HIPAA-compliant production where the professionals who deal with the issue can inquire for expert help with complex RLS cases.
HCPLive interviewed Winkelman during SLEEP 2025, the 39th annual meeting of the Associated Professional Sleep Societies, to talk about these new guidelines and how clinicians can proceed going forward with transitioning patients off dopamine agonists onto newer recommended therapies.
In some cases, the patients have been using dopamine agonists for over 4-5 years, and their condition is getting worse, hcplive.com reported.
“At that point, you’re going to describe the other approaches for restless legs [syndrome],” as Winkelman noted, “and there are other good approaches.”
The next part seeks out other factors contributing to the worsening of RLS, such as serotonergic antidepressants, sleep apnea, well-used antihistamines, dopamine antagonists used either for a psychiatric or GI purpose, and consumption of alcohol.
“First, we’re going to look at all those things that make it worse,” according to Winkelman.
“We’re going to try to modify them. If that doesn’t make a difference, we’re going to add one of these other medications or approaches. After we’ve started those other approaches and symptoms have [gotten] under better control, then we’re going to extremely carefully and slowly reduce the dose of the dopamine agonist. It takes, generally, 6 to 12 months to get people off the dopamine agonist,” the expert continued.